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The self-directed Hospice & Palliative Care Public Health Nurse (HPCPHN) provides skilled nursing assessment, planning & coordination/care Mgmt across settings to patients in a private home, adult foster home, residential/assisted living care, intermediate care, skilled nursing facility, inpatient hospice facilities & hospital settings in order to maximize the comfort & health of patients & families consistent w/hospice philosophy & CCS policies & procedures.
- Assume initial responsibility for assessing patient/family needs & consulting w/attending physician, Hospice & Palliative Care Physician (HPCP) , other IDT staff members or other appropriate community or facility contacts as indicated by patient location & needs at the time of the assessment & care provision.
- Obtain data on physical, psycho/social, emotional & spiritual factors that may influence patient/family health status & incorporate that data into the plan of care.
- Facilitate advanced illness &/or end of life discussion w/patient & family members to assist w/choice of hospice or palliative care.
- Determine patient appropriateness for palliative care or hospice srvs (including hospice level of care & care site) in consultation w/the HPCP.
- Case Mgmt: assume primary responsibility for a patient/family caseload that includes the assessing, planning, implementing & evaluating phases of the nursing process; including scheduling visits to reflect patient care needs in order to maintain continuity of the plan of care; & advocate for patient & family.
- Participate as an active member of the IDT to coordinate info & srvs to update the plan of care.
- Maintain up to date patient records so that problems, plans, actions & goals are accurately & clearly stated & changes are reflected as they occur in accordance w/CCS policies & procedures.
- Instruct primary caregivers, family members, employed caregivers & facility staff to provide hospice specific care as indicated.
- Attend weekly case conferences & actively participate in discussion of patient needs & care planning.
- Coordinate hospice care across settings to achieve smooth transitions of care & assure compliance w/the hospice plan of care through communication & documentation for family members, caregivers, facility staff as appropriate.
- Supervise & document Hospice Aide care delivery every two weeks.
- Provide adequate emotional & clinical support at the time of death.
- Provide input into the bereavement assessment & plan of care.
- Provide phone triage & support to patients/families as needed & requested.
- Partner w/agency Mgmt in the development & review of programs w/in Continuing Care Srvs Dept. Facilitate the initiation of cost effective & safe hospice & palliative care & provide consultation to clinicians regarding appropriate care setting alternatives.
- Assure professional competency through maintaining state-of-the-art skills & knowledge consistent w/state & Medicare regulations, JointCommission accreditation standards, applicable nurse practice acts & agency policies.
- Participate in CCS & KP orientation & in srv training for professional staff as well as agency & community programs as requested to promote professional growth & understanding of hospice & palliative care.
- Demonstrate familiarity w/policies of the agency & rules & regulations of state & federal bodies which aid in determining policies.
- Participates in Dept quality Mgmt/improvement activities; including but not limited to clinical record review, occurrence reporting, focused studies, process & outcome measurement, peer review, continuous quality improvement projects.
- Partner in defining & achieving agency productivity standards.
- Participates in hospice & palliative care 24 hour call duty consistent w/agency policy.
- Performs other duties as requested.
- One (1) year of medical-surgical nursing experience in an acute care setting or home health, hospice or palliative care, SNF, ALF settings.
- Baccalaureate degree in nursing or commensurate knowledge and experience (Commensurate knowledge and experience may include recent experience in areas of care coordination, case management, community hospice, pallative care or home health, and public health).
License, Certification, Registration
- Licensed in Oregon and Washington RN license. Requires license in primary state (Oregon or Washington) prior to first day of employment. Application for licensure in secondary state must be made within six (6) weeks of start date. Licenses in both states required within three (3) months of hire.
- Valid driver's license.
- Basic Life Support (BLS) CPR card for Health Care Provider. Valid card must be obtained prior to patient contact and within two (2) weeks of hire.
- Able to perform complete physical, psychosocial, spiritual assessments.
- Able to operate stethoscope and sphygmomanometer.
- Keyboarding or typing skills.
- Able to learn to operate a laptop computer to perform clinical documentation.
- Working knowledge of concise, yet thorough clinical documentation of patient assessments and care.
- Effective problem solving, written and verbal communication and organizational and time management skills required to accomplish case management responsibilities within allocated time frames.
- Note: This position requires completion of a typing test.
- Note: This position requires a reliable automobile to travel to and from patient homes.
- Experience working as a member of an interdisciplinary team.
- Certification in Hospice and Palliative Care Nursing.
- Hospice care and the dying process.
- Peripheral and central line IV management.
- Able to perform venipuncture and IV insertion.
- Able to operate multiple IV pumps.
- Operational knowledge of computerized clinical documentation and office application systems including the use of laptop/notebook computers.
- Working knowledge of the managed care industry.
- Knowledge of Medicare regulations/requirements.
- Excellent time management, problem solving and customer service skills.
- Excellent written and verbal communication skills.
- Able to work autonomously and manage patient caseload.
- Knowledgeable of the care for the chronically ill and frail elderly.
- Working knowledge of Hospice and palliative care for the terminally ill patient.
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